Visual Evoked Potential Abnormalities in Phelan-McDermid Syndrome

OBJECTIVE

The current study used visual evoked potentials (VEPs) to examine excitatory and inhibitory postsynaptic activity in children with Phelan-McDermid syndrome (PMS) and the association with genetic factors. PMS is caused by haploinsufficiency of SHANK3 on chromosome 22 and represents a common single-gene cause of autism spectrum disorder (ASD) and intellectual disability.

METHOD

Transient VEPs were obtained from 175 children, including 31 with PMS, 79 with idiopathic ASD, 45 typically developing controls, and 20 unaffected siblings of children with PMS. Stimuli included standard and short-duration contrast-reversing checkerboard conditions, and the reliability between these 2 conditions was assessed. Test-retest reliability and correlations with deletion size were explored in the group with PMS.

RESULTS

Children with PMS and, to a lesser extent, those with idiopathic ASD displayed significantly smaller amplitudes and decreased beta and gamma band activity relative to TD controls and PMS siblings. Across groups, high intraclass correlation coefficients were obtained between standard and short-duration conditions. In children with PMS, test-retest reliability was strong. Deletion size was significantly correlated with P₆₀-N₇₅ amplitude for both conditions.

CONCLUSION

Children with PMS displayed distinct transient VEP waveform abnormalities in both time and frequency domains that might reflect underlying glutamatergic deficits that were associated with deletion size. A similar response pattern was observed in a subset of children with idiopathic ASD. VEPs offer a noninvasive measure of excitatory and inhibitory neurotransmission that holds promise for stratification and surrogate endpoints in ongoing clinical trials in PMS and ASD.

Sensory Reactivity Phenotype in Phelan-McDermid Syndrome Is Distinct from Idiopathic ASD

Phelan–McDermid syndrome (PMS) is one of the most common genetic forms of autism spectrum disorder (ASD). While sensory reactivity symptoms are widely reported in idiopathic ASD (iASD), few studies have examined sensory symptoms in PMS. The current study delineates the sensory reactivity phenotype and examines genotype–phenotype interactions in a large sample of children with PMS. Sensory reactivity was measured in a group of 52 children with PMS, 132 children with iASD, and 54 typically developing (TD) children using the Sensory Assessment for Neurodevelopmental Disorders (SAND). The SAND is a clinician-administered observation and corresponding caregiver interview that captures sensory symptoms based on the DSM-5 criteria for ASD. Children with PMS demonstrated significantly greater hyporeactivity symptoms and fewer hyperreactivity and seeking symptoms compared to children with iASD and TD controls. There were no differences between those with Class I deletions or sequence variants and those with larger Class II deletions, suggesting that haploinsufficiency of SHANK3 is the main driver of the sensory phenotype seen in PMS. The syndrome-specific sensory phenotype identified in this study is distinct from other monogenic forms of ASD and offers insight into the potential role of SHANK3 deficiency in sensory reactivity. Understanding sensory reactivity abnormalities in PMS, in the context of known glutamatergic dysregulation, may inform future clinical trials in the syndrome.

Language ENvironment Analysis (LENA) in Phelan-McDermid Syndrome: Validity and Suggestions for Use in Minimally Verbal Children with Autism Spectrum Disorder

Phelan-McDermid syndrome (PMS) is a single-locus cause of developmental delay, autism spectrum disorder, and minimal verbal abilities. There is an urgent need to identify objective outcome measures of expressive language for use in this and other minimally verbal populations. One potential tool is an automated language processor called Language ENvironment Analysis (LENA). LENA was used to obtain over 542 h of audio in 18 children with PMS. LENA performance was adequate in a subset of children with PMS, specifically younger children and those with fewer stereotypic vocalizations. One LENA-derived language measure, Vocalization Ratio, had improved accuracy in this sample and may represent a novel expressive language measure for use in severely affected populations.

Phenotypic and functional analysis of SHANK3 stop mutations identified in individuals with ASD and/or ID

BACKGROUND

SHANK proteins are crucial for the formation and plasticity of excitatory synapses. Although mutations in all three SHANK genes are associated with autism spectrum disorder (ASD), SHANK3 appears to be the major ASD gene with a prevalence of approximately 0.5% for SHANK3 mutations in ASD, with higher rates in individuals with ASD and intellectual disability (ID). Interestingly, the most relevant mutations are typically de novo and often are frameshift or nonsense mutations resulting in a premature stop and a truncation of SHANK3 protein.

METHODS

We analyzed three different SHANK3 stop mutations that we identified in individuals with ASD and/or ID, one novel (c.5008A > T) and two that we recently described (c.1527G > A, c.2497delG). The mutations were inserted into the human SHANK3a sequence and analyzed for effects on subcellular localization and neuronal morphology when overexpressed in rat primary hippocampal neurons.

RESULTS

Clinically, all three individuals harboring these mutations had global developmental delays and ID. In our in vitro assay, c.1527G > A and c.2497delG both result in proteins that lack most of the SHANK3a C-terminus and accumulate in the nucleus of transfected cells. Cells expressing these mutants exhibit converging morphological phenotypes including reduced complexity of the dendritic tree, less spines, and less excitatory, but not inhibitory synapses. In contrast, the truncated protein based on c.5008A > T, which lacks only a short part of the sterile alpha motif (SAM) domain in the very SHANK3a C-terminus, does not accumulate in the nucleus and has minor effects on neuronal morphology.

CONCLUSIONS

In spite of the prevalence of SHANK3 disruptions in ASD and ID, only a few human mutations have been functionally characterized; here we characterize three additional mutations. Considering the transcriptional and functional complexity of SHANK3 in healthy neurons, we propose that any heterozygous stop mutation in SHANK3 will lead to a dysequilibrium of SHANK3 isoform expression and alterations in the stoichiometry of SHANK3 protein complexes, resulting in a distinct perturbation of neuronal morphology. This could explain why the clinical phenotype in all three individuals included in this study remains quite severe - regardless of whether there are disruptions in one or more SHANK3 interaction domains.

Risk factors for rape re-victimisation: a retrospective analysis

Sexual re-victimisation refers to a pattern in which the sexual assault victim has an increased risk of subsequent victimisation relative to an individual who was never victimised. The purpose of our study was to identify risks factors for a second rape, the severest form of sexual re-victimisation. All rape victims treated at the First Regional Israeli Center for Sexual Assault Victims between October 2000 and July 2010 were included in this retrospective analysis. We compared characteristics of 53 rape victims who were victimised twice to those of 1,939 rape victims who were victimised once. We identified several risk factors for a second rape, which can be used in prevention programmes. These are: psychiatric background, history of social services involvement, adulthood, non-virginity and minority ethnicity.

Is antibody screening in Rh (D)-positive pregnant women necessary?

OBJECTIVE

Hemolytic disease of the fetus and of the newborn can be caused by incompatibility of maternal and fetal erythrocytes for Rh (D) or other blood type antigens. Routine antibody screening is advocated in all pregnant women, irrespective of whether they are Rh (D)-positive or Rh (D)-negative, to look for clinically significant alloantibodies other than Rh (D) that might cause hemolytic disease of the newborn. The purpose of this study was to assess the incidence of blood type antibodies other than Rh (D) in pregnant women attending for prenatal care in a typical urban population.

METHODS

A retrospective analysis was undertaken of the charts of all pregnant women followed throughout their entire pregnancy at our Women's Health Center from 1 January 1999 to 30 April 2002.

RESULTS

There were 1265 pregnant women included in the study: 465 had blood type A (36.7%), 269 type B (21.3%), 424 type O (33.5%) and 107 type AB (8.5%). A total of 1156 were Rh (D)-positive (91.4%) and 109 were Rh (D)-negative (8.6%). Of the Rh (D)-positive women, 522 (41.3%) underwent routine antibody screening in the first trimester. Only one woman (0.2%) had a positive antibody screen. Of the 109 Rh (D)-negative women, one (0.9%) had a positive third trimester screen with a negative first trimester screen.

CONCLUSION

Routine antibody screening of Rh (D)-positive women is probably not warranted from a clinical cost-benefit perspective.

Relationship between uterine contractions and serum magnesium levels in patients treated for threatened preterm labour with intravenous magnesium sulphate

We aimed to correlate the assessment of preterm uterine activity with serum magnesium levels in women with threatened preterm labour. The observational study involved twelve women receiving intravenous magnesium sulphate for threatened preterm labour. Mean gestational age at initiation of therapy was 26.9+/-2.9 weeks. Mean cervical dilatation at initiation of therapy was 1.5 cm. Serum magnesium levels and evaluation of uterine contractions by external tocograph were assessed twice daily. Presence or absence of contractions was analysed for correlation with plasma magnesium levels. Eighty-eight measurements were analysed. The mean serum magnesium levels were 1.9+/-0.5 mmol/l and 1.9+/-0.3 mmol/l in the presence (n=22) or absence (n=66) of contractions, respectively. The difference did not reach statistical significance. No correlation was found between serum magnesium levels and presence of contractions (P=0.3, logistic regression odds ratio 1.1, 95% confidence interval of 0.6-2.0). The abolition of premature uterine contractions during intravenous magnesium sulphate therapy does not correlate with serum magnesium levels.

Low values on 50 gram glucose challenge test or oral 100 gram glucose tolerance test are associated with good perinatal outcome

We set out to reevaluate the hypothesis that high normal (negative) results of 50 g oral glucose challenge test or high normal glucose level on 100 g oral glucose tolerance test are associated with complications of pregnancy and delivery. This was a prospective study involving 735 nondiabetic women. The first group (n=352) was made up of pregnant women with normal 50 g oral glucose challenge test without previous history of diabetes mellitus or gestational diabetes. The second group (n=383) was made up of pregnant women without previous history of diabetes mellitus or gestational diabetes with an abnormal 50 g oral glucose challenge test and with normal 100 g oral glucose tolerance test and not more than one previous delivery. In nondiabetic women, we demonstrated a positive correlation between high normal 50 g glucose challenge test values and the incidence of preeclampsia, caesarean section rate, macrosomia, neonatal hyperlipidaemia and minor congenital abnormalities. We failed to confirm any relationship to any pregnancy complication in pregnant women with 2-hour glucose levels in the range 6.7-9.1 mmol/l on the 100 g oral glucose tolerance test. We have demonstrated a positive relationship between the incidence of premature rupture of membranes and 1-hour glucose level, caesarean section rate and maternal 1-hour glucose level or 1-hour glucose level minus fasting glucose level of 4.2 mmol/l, instrumental delivery rate and maternal 3-hour glucose level, incidence of neonatal macrosomia and 1-hour glucose level, and incidence of neonatal hyperlipidaemia and at least one high but normal glucose level on the 100 g oral glucose tolerance test. With regard to pregnancy and delivery complications there were no significant difference if the high normal value is on the 50 g glucose challenge test or on the 100 g oral glucose tolerance test. It is concluded that one high normal 100 g oral glucose tolerance test or high normal 50 g glucose challenge test are associated with adverse pregnancy and delivery outcome. Nondiabetic women with 50 g glucose challenge test value of 6.1 mmol/l and/or 100 g oral glucose tolerance test values of 5 mmol/l have a favourable pregnancy and delivery outcome.

Vacuum extraction and herpes simplex virus infection

OBJECTIVE

To search for an association between delivery by vacuum extraction and an increased neonatal risk for herpes simplex virus (HSV) infection.

METHODS

In a cross-sectional, descriptive, controlled study, the study (vacuum extraction) and control (spontaneous delivery) groups each included 50 consecutive women with no history of HSV infection. Cultures for HSV were obtained from the genital tracts of all parturient women and the scalps of their newborns.

RESULTS

Following operative vaginal delivery, two newborns (4%) had scalp vesicles and cultures were positive for HSV for both mothers and newborns; two newborns (4%) had scalp vesicles and cultures were negative for HSV; and two newborns (4%) without scalp vesicles had cultures positive for HSV. Following spontaneous delivery, cultures were positive for HSV for four women and their newborns (8%).

CONCLUSION

Herpes simplex virus isolated from the scalps of newborns may often result from colonization rather than infection.

The threat of type IV Ehlers-Danlos syndrome on maternal well-being during pregnancy: early delivery may make the difference

We describe a successful management of a pregnancy in a woman with type IV Ehlers-Danlos syndrome that included an elective caesarean section and tubal ligation at 32 weeks' gestation. We identified 26 women (including ours) who had been pregnant with well-documented characteristics of type IV Ehlers-Danlos syndrome in the literature. These 26 women had 50 pregnancies. Ten (38.5%) died during pregnancy or in the immediate postpartum period. The maternal mortality rate per pregnancy in type IV Ehlers-Danlos syndrome was therefore calculated to be 20.0%. Pregnancy, continuing pregnancy, or subsequent pregnancy are all contraindicated in patients with type IV Ehlers-Danlos syndrome. Termination of pregnancy before 16 weeks' gestation should be strongly advised. If the patient proceeds with pregnancy, restriction of physical activity at the beginning of third trimester, frequent evaluation of the patient, and an elective caesarean delivery at 32 weeks' gestation after an appropriate antenatal steroid therapy should be advised.

Thermal death kinetics of egg and third instar Mediterranean fruit fly (Diptera: Tephritidae)

Two developmental stages of Ceratitis capitata (Wiedemann), 24-h-old eggs and third instars, 8 d after oviposition, were subjected to thermal exposures in a heating block system, at various temperatures of 46, 48, 50, and 52 degrees C to determine the thermal death kinetics of the insects. At these temperatures, 100% mortality was achieved by exposure of 300 C. capitata larvae for 60, 15, 4, and 1 min, respectively. The 0.5 order kinetic model had the best fit to the survival ratio for all the treatment temperatures, hence it was used for the prediction of the lethal times. The thermal death time (TDT) curves showed that the third instars were more heat-resistant than eggs, especially at the two low temperatures (46 and 48 degrees C). Under temperature-time combinations that did not result in complete kill, the thermal mortality for eggs was also significantly higher than that for third instars. The activation energy values calculated from the TDT curves were 490.6 and 551.9 kJ/mol, respectively, for thermal death of eggs and third instars.

Caesarean delivery during maternal cardiopulmonary resuscitation for status asthmaticus

A patient who sustained a recurrent cardiopulmonary resuscitation due to status asthmaticus during one pregnancy followed by a birth of an apparently normal infant is described. Promptly performed caesarean delivery might have saved the mother and her infant. Cardiopulmonary resuscitation is less effective in a near term pregnant woman.

Assessment of a newer technique for cesarean section

We present a new method for cesarean section that predominantly employs blunt techniques. We used it in 51 patients having a first cesarean section and compared the results with 51 matched controls having a standard technique first cesarean section.

Symptomatic hyponatremia following cesarean section

A rare occurrence of the syndrome of inappropriate antidiuretic hormone secretion is described in a 32-year-old previously healthy nulliparous woman who underwent a Cesarean section for non-progressive labor.

Value of vaginal culture in management of acute vaginitis

OBJECTIVE

To evaluate the relative contribution of clinical assessment and vaginal discharge cultures in the treatment of acute vaginitis.

METHODS

A prospective observational study of 75 consecutive sexually active women with acute vaginal symptoms was undertaken. Each patient underwent an evaluation that included a standardized history, interview a thorough pelvic examination and vaginal culture. The treatment was administered based upon patient symptomatology and macroscopic appearance of vaginal discharge.

RESULTS

There was an agreement between initial diagnosis and culture isolates in 38 patients (50.6%). Of the 75 enrolled women 9 have not returned for reevaluation 8 days after initiation of the treatment. Fifty three (80.3%) of the remaining 66 women were free of symptoms 8 days after initiation of the treatment. The remaining 13 women were treated successfully in accordance with the vaginal culture result.

CONCLUSION

A high cure rate of acute vaginitis could be achieved based upon physical examination. Vaginal cultures are valuable in initial therapy failures.

Adnexal torsion with a paraovarian cyst in a teenage girl

Adnexal torsion with a paraovarian cyst in adolescent or premenarchal girls is extremely rare and very difficult to diagnose before surgery. We identified three published cases of the disorder in adolescent or premenarchal girls. Our patient, a 12.5-year-old girl, is the fourth. The cyst was excised and the adnexa untwisted at laparoscopy. High awareness and timely laparoscopy contributed to conservation of the adnexa in our young patient.

Red blood cell survival and kinetics during pregnancy

Profound changes occur during pregnancy in the maternal hematopoietic system in order to meet the needs of the developing fetus and of the mother. By presenting the available data in one review, this review links all known hematopoietic events that occur during normal and certain abnormal pregnancies. Erythropoietin and erythrocyte production are increased during normal pregnancy while erythrocyte mass per unit of body weight remains constant throughout the entire pregnancy, and hemoglobin and hematocrit continuously decrease into the third trimester. Erythrocyte life span is decreased during normal pregnancy due to 'emergency hemopoiesis' in response to elevated erythropoietin levels. In preeclampsia, maternal erythrocytes are of similar to non-pregnant state age distribution, while fetal erythrocytes are of younger age distribution than in normal pregnancy. In gestational diabetes, maternal erythrocyte age distribution is similar to that of normal pregnancy. In multifetal pregnancy, maternal erythrocyte age distribution is younger than that of normal pregnancy.

Continuous-flow vaginoscopy in children and adolescents

STUDY OBJECTIVE

To assess the role of continuous-flow vaginoscopy in the management of gynecologic problems in pediatric and adolescent patients.

DESIGN

Prospective, observational study (Canadian Task Force classification II-3). Setting. University-affiliated teaching hospital.

PATIENTS

Twenty-two consecutive children and adolescents evaluated for vulvovaginitis (15), vaginal trauma (4), bleeding (2), and genital malformation (1).

INTERVENTION

Continuous-flow vaginoscopy with a 4-mm hysteroscope under general anesthesia.

MEASUREMENTS AND MAIN RESULTS

Vaginal walls, fornices, and cervices were well visualized in all patients. No pathologic findings were found in 16, a foreign body was present in 3, and vaginal lacerations in 3. Foreign material was removed with long straight forceps, bleeding spots were coagulated, and lacerations sutured. No complications occurred. The patients were discharged 4 to 24 hours after the procedure.

CONCLUSION

Diagnosis of gynecologic problems in children and adolescents should include vaginoscopy. Continuous-flow vaginoscopy is quick and easy to perform in these patients.

Comparison of the differential distribution of leukocytes in preeclampsia versus uncomplicated pregnancy

OBJECTIVE

To describe leukocyte count and differential distribution in preeclampsia and uncomplicated pregnancy.

STUDY DESIGN

Blood samples were obtained from 46 consecutive preeclamptic patients and 46 controls with uncomplicated pregnancy. Thirty met the criteria for mild preeclampsia and 16 for severe. The blood was tested within 1 h of venepuncture. An aliquot of the blood was tested in the Cell-Dyn 2000 for complete blood cell count.

MAIN RESULTS

The absolute neutrophil count was significantly elevated in preeclamptic patients as compared with that of controls with uncomplicated pregnancy (9,410.1+/-3,066.9 vs. 7,498.6+/-2,354.0 x 10(6)/l, p < 0.05). In neutrophils, the elevation was more prominent in severe preeclamptic patients as compared with mild preeclamptic patients (10,658.8+/-3520.4 vs. 8,694.4+/-2,561.9 x 10(6)/l, p < 0.05). The absolute lymphocyte and eosinophil counts declined in patients with preeclampsia as compared with uncomplicated pregnancy, whereas monocyte and basophil counts did not differ.

CONCLUSION

Our results suggest that preeclampsia is associated with an increase in the absolute neutrophil count.

Meigs' syndrome: the history of the eponym

Meigs' syndrome is defined as presence of ascites with hydrothorax in association with benign ovarian tumor. The syndrome is named after Joe Vincent Meigs (1892-1963), a Harvard Medical School Professor of Gynecology. However, it was described by several authors in the 19th and the beginning of 20th centuries. Meigs and Cass deserve the credit for awakening the medical profession to the importance of the syndrome in 1937. At the end, the syndrome was coined Meigs' syndrome by Rhodes and Terrell in 1937.

Pectin esterase, polygalacturonase and gel formation in peach pectin fractions

Peaches (Prunus persica cv. Hermoza) were stored at 0C in regular air (RA) or in controlled atmosphere (CA 10% CO2, 3% O2) for 4 weeks and then ripened for 4 days at 20 degrees C. Woolliness developed in the regular air stored fruit while the controlled atmosphere stored fruit ripened normally. In the woolly fruit symptoms of the disorder were greater in the inner mesocarp than in the outer. Polygalacturonase (PG) and pectin esterase (PE) activities differed in the outer and inner mesocarp of the affected fruit. PG activity was low and PE activity was high in the inner mesocarp of the woolly fruit during ripening relative to the outer mesocarp, while in the healthy fruit, activities were similar in both areas. Cell wall fractions of water-soluble, CDTA-soluble and carbonate-soluble pectins were prepared from freshly harvested peaches and incubated with PE and PG from ripe peaches at different ratios. Only the CDTA-soluble fraction formed a gel with peach enzymes, and the rate of gelation increased with increasing amounts of PE relative to PG. Both water-soluble and CDTA-soluble pectin fractions formed gels with commercial PE (extracted from orange peel). The PE extracted from peaches was stable when stored at 0 degrees C for 9 days, while PG activity was stable only for 1 day. We suggest that PE, acting on pectins in the cell wall in vivo may cause gel formation and that the CDTA-soluble polymers have the capacity to bind apoplastic water and create the dry appearance observed in woolly fruit.

Non-adherence in pediatric liver transplant recipients--an assessment of risk factors and natural history

Despite the fact that non-adherence to medical therapy is one of the major causes of late morbidity and mortality in pediatric liver transplant recipients, little is known of the risk factors involved in this behavior. Three cases of fatal non-adherence are reported. Factors associated with non-adherence were investigated by performing a retrospective chart review of a panel of 27 variables in an age-matched cohort of 15 pediatric liver transplant recipients. The most striking differences between the severely non-adherent group and the age-matched cohort included history of substance abuse, child abuse (physical or sexual), not having two parents at home, having received public assistance, having been diagnosed with a psychiatric disorder, and history of school dropout. In addition it appeared that a pretransplant diagnosis of autoimmune hepatitis was associated with more significant medical sequelae related to non-adherence. These findings are preliminary owing to the retrospective design of this study, but could be used as a starting point for a prospective study of this important phenomenon.

Transient myocardial ischemia may occur following subendometrial vasopressin infiltration

A case of transient myocardial ischemia following subendometrial vasopressin infiltration in intractable intra-operative postpartum bleeding due to placenta accreta is described. In our experience, the rate of this side effect is one in 14 patients (rate of 7.1%). We believe that the benefits of the treatment outweigh the risks, since the uterus was saved in all 14 patients. Nevertheless, this case emphasises that extreme precaution is needed with subendometrial vasopressin infiltration. It should be emphasised that the needle must not be within a blood vessel because intravascular injection of vasopressin solution can precipitate acute arterial hypertension, bradycardia and even death. We suggest that local vasopressin infiltration into the placental site is indicated in cases of intractable bleeding at cesarean section after other conventional obstetric and pharmacological maneuvers have failed.

Characteristics of normal lochia

The objective of this paper is to determine the characteristics of each phase of lochia and how these may be influenced by a number of obstetric variables. Thirty-nine healthy women who had spontaneous vaginal delivery following uncomplicated pregnancy volunteered to complete a diary sheet immediately postpartum. The women were instructed to assess the color of their lochia by a color slide with differential gradation from dark red to white. The color was labeled as rubra (red, red-brown), serosa (brown-pink, brown), or alba (yellow, white). The overall duration of lochia was 36.0 +/- 7.5 days (range 17 to 51 days, median 37 days). Three types of lochia color patterns were identified: type 1--rubra-->serosa-->alba sequence (n = 20); type 2-rubra-->serosa-->alba sequence with prolonged rubra phase and short serosa and alba phases (n = 11); and type 3-with two rubra phases (rubra-->serosa/alba-->rubra-->serosa/alba sequence with near-equal duration of each phase) (n = 8). The rubra phase lasts 12.1 +/- 6.7 days in type 1, 24.8 +/- 5.0 days in type 2, and 5.5 +/- 2.5 days (the first rubra) in type 3 pattern (p < 0.05). There was a higher proportion of lactating women among women with type 1 pattern as compared with type 2 (11/20 and 2/11, p < 0.05, respectively). Women with type 2 pattern were of higher parity (2.8 +/- 1.3) as compared with those with type 1 (1.8 +/- 0.8) (p < 0.05). There were no significant differences in infants' birth weight between the various color types (3,276.0 +/- 379.8 g, 3,564.4 +/- 737.9 g, and 3,080.0 +/- 180.0 g for type 1, type 2, and type 3, respectively. There were no significant differences in overall duration of lochia or gestational age at delivery between the various color types. The results confirm the clinical impression that lochia persists longer than classically reported and is of diverse patterns. Three unique types of color patterns were identified. Type 1 is the most prevalent and is associated with prolonged breast feeding and thus can be considered as the classic type. Type 2 is associated with short or no breast feeding and higher parity. Type 3 may be a variant of type 2. We suggest that traditional teaching on lochia characteristics needs reappraisal.

A pilot study of posttraumatic stress and nonadherence in pediatric liver transplant recipients

BACKGROUND

Symptoms of posttraumatic stress disorder (PTSD) were described in survivors of life-threatening diseases, the trauma being the experiences associated with the disease or its treatment. Their prevalence in liver transplant recipients is unknown. Based on clinical observations, we hypothesize that a significant proportion of pediatric liver transplant recipients suffers from PTSD symptoms. We further hypothesize that nonadherence (noncompliance) to medical management may, in some cases, be associated with these symptoms. Traumatized patients, according to this hypothesis, will avoid taking their medications, because these serve as painful reminders of the disease.

OBJECTIVES

To determine the prevalence of PTSD symptoms in a sample of pediatric liver transplant recipients. To determine whether symptoms of PTSD are associated with nonadherence in these patients. To describe the clinical presentation of PTSD and the management of severe nonadherence in patients who suffer from this disorder.

METHODS

Nineteen pediatric liver transplant recipients and their caretakers were interviewed, using the UCLA Post Traumatic Stress Disorder Reaction Index (PTSRI). Data were obtained on a few demographic parameters and perception of disease threat. Adherence was evaluated by 2 methods: 1) a clinician panel (taking into account the clinical sequelae of severe nonadherence); and 2) computation of the standard deviations (SDs) of consecutive determinations of blood levels of Tacrolimus (a higher SD means higher variability between individual measures and is therefore an indicator of nonadherence). As an illustration of the general phenomenon, we describe 3 cases of liver transplant recipients who were nonadherent and who suffered from PTSD.

RESULTS

Six of 19 patients had positive scores on all 3 components of the PTSRI (PTSD patients). Three of these, and none of the others, were considered significantly nonadherent by the panel. Therefore, nonadherence was significantly associated with the existence of symptoms from all 3 domains of PTSD (Fisher's exact test) in our sample. In particular, a high avoidance score on the PTSRI was highly correlated with panel-determined nonadherence. Further, SD of medication levels were significantly higher in PTSD patients, compared with the rest of our sample. No significant differences were found in perception of disease threat or demographic variables between PTSD patients and the rest of our sample. The 3 cases that we describe became adherent to their medications when symptoms of PTSD subsided during the course of therapy.

CONCLUSIONS

Clinically significant nonadherence, determined by 2 different methods, was associated with the full spectrum of PTSD symptoms in this sample. It was especially associated with a high avoidance score, which suggests that avoidance of reminders of the disease (eg, medications) may be a mechanism of nonadherence. Screening for and management of these symptoms, therefore, may improve adherence. This novel concept may be applicable to other patient populations. However, more data are needed before any definite conclusions can be drawn.

Assisted internal autorotation with vacuum extractor. Description of an original maneuver

The traditional treatment of arrest of internal rotation of fetal head is forceps. We describe a maneuver for assisted internal autorotation of fetal head with vacuum extractor. We have used this approach in 30 parturients. No neonatal or maternal complications were noted.

Disseminated intravascular coagulopathy in pregnancy: thorough comprehension of etiology and management reduces obstetricians' stress

In pregnancy and puerperium disseminated intravascular coagulopathy may accompany abruptio placenta, intrauterine fetal demise with retained dead fetus, amniotic fluid embolism, endotoxin sepsis, preecalampsia with HELLP and massive transfusion. Clinical signs and symptoms of DIC can include oozing from venipuncture sites and/or mucous membranes, red cell lysis from activation of the complement system, hemorrhage from coagulopathy and possible uterine atony, hypotension from hemorrhage and/or bradykinin release, and oliguria from end-organ insult and hypovolemia/hypotension. Treatment of DIC consists of replacement of volume, blood products, and coagulation components and cardiovascular and respiratory support with elimination of underlying triggering mechanism.

Human fetal-placental weight ratio in normal singleton near-term pregnancies

OBJECTIVE

To determine the fetal-placental weight ratio in normal near-term singleton pregnancies.

PATIENTS AND METHODS

431 consecutive singleton near-term live deliveries following uncomplicated pregnancies were included in a prospective study. Mean maternal age was 28.6 years (range 17-50), mean parity was 2.9 (range 1-16). Mean gestation age at delivery was 39.7 weeks (range 33-42).

RESULTS

Mean newborn weight was 3,382.1 +/- 486.7 g (range 2,180-4,810). Mean placental weight was 613.0 +/- 123.8 g (range 319-1,266). Mean fetal-placental weight ratio was 5.6 +/- 0.96 (range 2.9-10.6) with kurtosis of 3.6 and skewness of 1.05. The ratio did not differ significantly between male (n = 253) and female (n = 176) infants, 5.7 +/- 0.89 and 5.6 +/- 1.04, respectively. There was a progressive increase in the fetal-placental weight ratio with gestational age (r = 0.87): from 5.3 +/- 0.90 at 33-36 weeks to 5.9 +/- 1.06 at the 41st week and 5.7 +/- 0.71 at the 42nd week (p < 0.05) and with birth weight distribution (r = 0.85) from 5.0 +/- 1. 06 in newborns weighing 2,000-2,499 g to 5.9 +/- 0.94 in newborns weighing >4,000 g (p < 0.05). There was a positive relationship between the fetal-placental weight ratio in teenage and elder parturients (r = 0.98): 5.2 +/- 0.98 (age 17-19), 5.7 +/- 0.88 (age 20-29), 5.6 +/- 1.08 (age 30-39), and 5.7 +/- 0.96 (age 41-50) (p < 0.05). The most contributing variable was birth weight.

CONCLUSIONS

The fetal-placental weight ratio tends to be low in teenage women, early near-term gestational age, and low fetal weight. There was a progressive increase in the fetal-placental weight ratio with gestational age and with birth weight distribution.

Uterine flora at cesarean and its relationship to postpartum endometritis

OBJECTIVE

To evaluate the relationship between the presence of microorganisms at the time of cesarean at different sites of the genital tract and the development of postpartum endometritus.

METHODS

One-hundred thirty-three healthy women who delivered by cesarean were enrolled in this prospective study. Cultures were obtained during the surgery and on days 3-5 postoperatively. Gram staining of uterine cavity fluid was done on days 3-5. Gram stains were examined under a high-power microscope for the presence of polymorphonuclear leukocytes.

RESULTS

Twenty patients (15.0%) met the criteria for postpartum endometritis. Forty-five patients (33.8%) had one or more positive cultures (n = 133) at the time of surgery, resulting in 93 positive cultures and 123 bacterial isolates. Forty-four patients had positive postoperative uterine cavity cultures at days 3-5 postpartum, resulting in 65 isolates. Of 44 patients with a positive postoperative culture, 26 (59.1%) also had Gram stain positive for polymorphonuclear leukocytes in the uterine cavity fluid, whereas only six of 89 patients (6.7%) with negative postoperative culture had a positive Gram stain (P < .05). The relative risk of having a positive culture on postoperative day 3-5 if the culture at surgery was positive at any site was 15.6 (95% confidence interval [CI] 5.9, 42.2), and it was 19.5 (95% CI 6.8, 57.8) if the culture was positive at the lower uterine segment.

CONCLUSION

The presence of bacteria in the lower uterine segment at the time of the surgery predicts their presence in the uterine cavity during puerperium. The Gram stain of uterine cavity fluid on postcesarean days 3-5 is another quick tool that can expedite the diagnosis of postpartum endometritis.